Stroke, together with heart disease, accounts for the largest proportion of non-communicable diseases and deaths worldwide. In the US, there are 795,000 annual stroke cases and 150,000 deaths from stroke. Numbers will steeply increase with the aging population. Stroke remains the main cause of serious long-term disability with minorities being affected disproportionally. Greater risk of stroke exists among blacks and Hispanics at younger ages; blacks have greater stroke mortality. Though measures of quality of stroke care during acute hospitalization have improved, little evidence exists on the quality of processes leading to effective stroke prevention and rehabilitation after hospital discharge. Unexpected hospital readmissions 30 days after acute stroke hospitalization are common, as high as 25%, and lead to excess morbidity and cost. Stroke impact on patients', families', and communities' quality of life, and the burden on use and cost of health care is enormous. We propose the Transitions of Care Stroke Disparity Study (TCSD-S) with the main objective to identify race- ethnic and sex disparities in hospital-to-home transition of stroke care and outcomes, social determinants of health associated with these disparities, and to develop effective hospital-initiated system level initiatives to reduce disparities and readmissions, and to improve stroke outcomes. To achieve this objective, we will capitalize on the rich infrastructure and resources of our unique Florida Stroke Registry (FSR), which includes a well-developed network of hospitals, health providers, partnership with the AHA, and other Florida stakeholders. We will evaluate medication adherence, healthy lifestyle, utilization of rehabilitation interventions and medical follow-up 30 days after hospital discharge to home across representative Florida Comprehensive Stroke Centers. A novel Transitions of Stroke Care Performance Index (TOSC PI) will be derived and validated. Thi index will be a primary outcome together with hospital readmissions and stroke outcomes (disability, recurrence, cardiovascular events, and death). Data on TOSC and stroke outcomes will be collected by structured telephone interviews at 30 and 90 days after discharge and review of patient charts. Predictors of TOSC disparities and outcomes will be evaluated using baseline in-hospital data of the index stroke obtained from the FSR, and Social Determinants of Health obtained through a novel data collection instrument from publicly available records. Based on identified predictors of TOSC disparities, we will develop and assess the feasibility of initiatives to reduce TOSC disparities, targeting systems of care with a TOSC disparities dashboard, and health care providers with a training module for enhanced patient education and support at discharge and during follow-up. We will compare the TOSC PI and outcomes before and after the initiatives. The successful completion of this study will identify disparities in hospital-to-home TOSC, define key predictors of poor TOSC and stroke outcomes, and develop initiatives which will be scalable across health systems and which will address disparities, readmission rates, and poor outcomes.